Fill and Sign the Bureau of Monitoring and Audit Florida Department of Form

Form DFS-F2-SI -1 (8/2009) \ Page 1 of 3 Rule 69L -5.226, F.A.C. FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION BUREAU OF MONITORING AND AUDIT SELF -INSURANCE SECTION APPLICATION FOR SELF -INSURANCE INSTRUCTIONS All information entered on this application must be typewritten . The application and all accompanying documents must be filed in duplicate to: Florida Self- Insurers Guaranty Association, Inc., 1427 E ast Piedmont Drive ., 2 nd Floor, Tallahassee, Florida 32308, (hereinafter referred to as the Association .) All financial information submitted with this application must be prepared in accordance with United States Generally Accepted Accounting Principles. The current fiscal year -end financial statements as well as the prior fiscal year -end statement s must accompany this application. If the financial statements are not on a comparative basis with the prior year, then the three most recent statements must be submitted. The most recent year financial statements must be audited in accordance with Generally Accepted Auditing Standards. If financ ial statements for the two prior years have been audited in accordance with Generally Accepted Auditing Standards, then those audited financial statements must be submitted as well. If the date of the latest audited financial statements is over six months old at the time of application, interim financial statements up to and including at least the latest fiscal quarter must be included and must be certified as to their accuracy by a corporate officer, general partner, or sole proprietor. All financial information submitted with this application must be in the name entered on Line 1 below. The undersigned employer (hereinafter referred to as the Applicant), an employer subject to the provisions of the Florida Workers' Compensation Law, hereby makes applicati on for the status of a self-insurer in order to pay compensation directly. In connection with such application, the Applicant makes the following declarations for the purpose of enabling the Division of Workers' Compensation (hereinafter referred to as the Division) to make a finding of facts as to whether the Applicant meets the qualifications for self- insurance established in Rule 69L -5, Florida Administrative Code. The Association will review this application and accompanying documents and will advise t he Applicant in writing of any additional requirements imposed by Rule 69L -5, Florida Administrative Code. All requirements shall be fulfilled prior to the Division's approval of this application. The approval or denial of this application is governed by S ections 120.57 and 120.60, Florida Statutes and the applicable rules of procedure. In the event this application is denied, the Applicant shall have the right to request an administrative hearing on the denial of the application in accordance with Sections 120.57 and 120.60, Florida Statutes. If all requirements to self- insure are not met within 90 days of the date of application, the Division reserves the right to deny this application without prejudice. 1. Name of Applicant: 2. Applicant's Fed eral Employer Identification Numbe r: 3. Address (Princip al Office): 3a. Telephone Number: 4. Attach a list of all subsidiary or affiliated companies which are to be included under the applicant's self- insurance privilege. Indicate the percentage ownership of the applicant in each subsidiary or affiliated company. Include the address of each Florida location for each subsidiary or affiliated company. 5. Applicant is a (check one) : Corporation, Partnership, Individual Proprietorship, Other ______________ Attach proof that applicant or subsidiaries are registered Florida corporations. Form DFS-F2-SI -1 (8/2009) \ Page 2 of 3 Rule 69L -5.226, F.A.C. 6. Name of employee wh o will coordinate self -insurance program 6a. Title: 6b. Address if different from #3 above: 6c.Telephone number if different from #3a above: 7. D escribe briefly the general nature of the operations performed in Florida or the items manufactured in Florida: 8. Applicant's primary North American Industry Classification (NAIC) Code : 9. Describe briefly all work performed away from Florida locations : 10. Year business established: If a corporation, under laws of what state? 11. Did you succeed anyone? If so, whom? 12. Name of workers' compensation carrier at time of application : 13. What is the renewal date for your current workers' compensation coverage? 14. Attach a completed Certification of Servicing (Form DFS -F2 -SI-19). 15. Attach a copy of at least your current experience modification rating, past two (2) if available. 16. Giv e the following estimated payroll information for your first twelve ( 12) months of self -insurance. Provide the payroll classifications assigned to your operations using the classification system established by the National Council on Compensation Insurance. AMOUNT OF PAYROLL BY OCCUPATIONAL CLASSIFICATION FOR DIVISION USE ONLY No. of Employees Occupation Payroll Payroll Class. Manual Annual Rate Gross Premium Total Premium $ _________________________ Form DFS-F2-SI -1 (8/2009) \ Page 3 of 3 Rule 69L -5.226, F.A.C. 17. If a corporation, attach a list of the name and city and state of residence of each corporate officer; if a partnership, the name and city and state of residence of each partner; if an individual proprietorship, the name and city and state of residence of the owner. 18. If a limited partnership, give the date of formation and duration of partnership. 19. Is the applicant a subsidiary? If so, give the name and address of parent company : 20. In consideration of the approval of this application, the A pplicant hereby expressly understands and agrees to the following: a. To maintain such security deposits and excess insurance as required by the rules of the D ivision. b. To abide by all prov ision of Chapter 440, Florida Statutes, the Florida Workers’ Compens ation Law and all rules of the D ivision. c. That the authorization to self -insure may be revoked for cause at the discretion of the D ivision as provided by Section 440.38, Florida Statutes. d. To fully discharge by cash payments all amounts required to be paid by the provisions of the Workers' Compensation Law within the time periods prescribed by law. e. To pay to the D ivision all assessments required by Chapter 440, Florida Statutes. f. To pay to the Florida Self- Insurers Guaranty Association, Inc. all assessments required by Section 4 40.385, Florida Statutes and Plan of Operation of the Florida Self- Insurers Guaranty Association, Inc. g. That the self -insurance authorization extended upon approval of th is application applies only to the A pplicant and such affiliates or subsidiaries in which it has a majority ownership interest and which are included on this application. h. That affiliates or subsidiaries in which the A pplicant has majority ownership interes t may be included under its self -insurance authorization up on written notification to the Association . i. That the self -insurance authorization extended upon approval of this application will not include any affiliates or subsidiaries in which the applicant n o longer has a majority ownership interest and such authorization will expire and terminate without prior notice on the date that the A pplicant relinquishes a majority ownership interest. j. That the self -insurance authorization extended upon approval of this applica tion will be revoked by the D ivision when the equity structure of the A pplicant changes from that indicated by its application . That is, if the A pplicant is sold, merged, dis solved or otherwise changes its equity structure to the extent that the financial information upon which the self- insurance authorization was granted can no longer be used to determine the A pplicant's financial strength. I, , certify that all businesses included under this application are in compliance with the coverage requirements of the workers' compensation law contained in Section 440.38(1), Florida Statutes and that all such businesses will remain in compliance with this section pending approval of this application . I further certify that all information contained in this application is true and correct to the best of my knowledge and that the Applicant has not experienced a material adverse change in its financial condition since the date of the latest audited financial statements. Applicant _______________________________________ (Employer Name) By:_________________________________________ (Signature) Title:________________________________________ (Owner, Partner or Corporate Officer)